Table 2.
Part A: Insomnia Diagnosis: Child’s sleep habits in the last 3 months | Score | |
---|---|---|
Date | • Child’s name | Age |
The Child goes to bed reluctantly |
• Never (1) • Occasionally (1–2 per month or less (2) • Sometimes (once or twice per week) (3) • Often (3–5 times per week (4) • Always (daily) (5) |
|
The child has difficulty getting to sleep at night |
• Never (1) • Occasionally (1–2 per month or less (2) • Sometimes (once or twice per week) (3) • Often (3–5 times per week (4) • Always (daily) (5) |
|
The child feels anxious or afraid when falling asleep |
• Never (1) • Occasionally (1–2 per month or less (2) • Sometimes (once or twice per week) (3) • Often (3–5 times per week (4) • Always (daily) (5) |
|
The child wakes up more than twice per night |
• Never (1) • Occasionally (1–2 per month or less (2) • Sometimes (once or twice per week) (3) • Often (3–5 times per week (4) • Always (daily) (5) |
|
After waking up in the night, the child has difficulty to fall asleep again |
• Never (1) • Occasionally (1–2 per month or less (2) • Sometimes (once or twice per week) (3) • Often (3–5 times per week (4) • Always (daily) (5) |
|
How many hours of sleep does your child get on most nights? |
• 9–11 h (1) • 8–9 h (2) • 7–8 h (3) • 5–7 h (4) • Less than 5 h (5) |
|
How long, after going to bed, does your child usually fall asleep? |
• Less than 15 min (1) • 15–30 min (2) • 30–45 min (3) • 45–60 min (4) • More than 60 min (5) |
|
Total Score (sum of subscale scores) Score 10 or lower: unlikely to have insomnia Score 11–16: at risk of having insomnia Score 17 or higher: insomnia |
Part B: Discussion/Referral to sleep specialist: | Score | |
---|---|---|
The Child shows one or more of the following: • startles or jerks parts of the body while falling asleep and/or while asleep • often changes position • kicks the covers off the bed • shows repetitive actions such as rocking or head banging while falling asleep |
• Never (1) • Occasionally (1–2 per month or less (2) • Sometimes (once or twice per week) (3) • Often (3–5 times per week) (4) • Always (daily) (5) |
|
The child snores loudly and/or has difficulty breathing during the night |
• Never (1) • Occasionally (1–2 per month or less (2) • Sometimes (once or twice per week) (3) • Often (3–5 times per week (4) • Always (daily) (5) |
|
The Child shows one or more of the following: wakes up from sleep screaming or confused sleep walks has recurrent nightmares |
• Never (1) • Occasionally (1–2 per month or less (2) • Sometimes (once or twice per week) (3) • Often (3–5 times per week (4) • Always (daily) (5) |
|
Score 3 or higher on any item: consider discussion and or referral to sleep specialist | Number of scores ≥ 3 |